Prevalence of silent celiac disease in patients with dyspepsia

Celiac disease seroprevalence in subjects with dyspeptic symptoms. A study on a Mexican population

INTRODUCTION AND AIMS

Celiac disease (CD) is an autoimmune enteropathy that develops in genetically susceptible individuals. The typical gastrointestinal manifestation is diarrhea but symptoms of dyspepsia, such as epigastric pain, nausea, or satiety, can sometimes appear. Previous studies have reported that the prevalence of CD in patients with dyspepsia can be as high as 7%. The aim of the present study was to evaluate CD seroprevalence in subjects with dyspeptic symptoms and a control group in a Mexican population.

MATERIAL AND METHODS

A case-control study was conducted on blood donors that answered the PAGI-SYM questionnaire for dyspepsia and in whom IgA antibodies to tissue transglutaminase 2 (IgA anti-tTG2) and IgG antibodies to deamidated gliadin peptide (IgG anti-DGP) were determined. CD seroprevalence in subjects with dyspeptic symptoms and in asymptomatic subjects was compared.

RESULTS

A total of 427 subjects (76.3% men), with a mean patient age of 34 years (range of 18-65 years) were included. Of those participants, 87 (20.3%) had symptoms of dyspepsia (group A) and 340 (79.6%) were asymptomatic (group B). Antibodies were positive in one (1.15%) of the group A subjects (1/87, 95% CI 0.2-6 %), whereas they were positive in 4 (1.18%) of the group B subjects (4/340, 95% CI 0.4-2.9%, p = 0.59).

CONCLUSIONS

CD seroprevalence in the study population with dyspeptic symptoms (1%) was not different from that of the control population. Thus, CD screening in Mexican patients with dyspepsia is not justified.

The Prevalence of the Celiac Disease in Patients with Dyspepsia: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with celiac disease (CeD) can commonly present with symptoms of dyspepsia. We conducted a systematic review and meta-analysis of the present literature to assess the prevalence of CeD in patients diagnosed with dyspepsia.

METHODS

We searched MEDLINE and EMBASE databases for the keywords: celiac disease, coeliac disease, anti-gliadin, tissue transglutaminase antibody, anti-endomysial antibody, dyspepsia and functional gastrointestinal disorder. All the studies published from January 1991 till May 2021 were included. Diagnosis of CeD was based on the European Society of Pediatric Gastroenterology, Hepatology and Nutrition guidelines. A random-effects model was used to pool the data.

RESULTS

Twenty-one studies screening 10,275 patients with dyspepsia were included. The pooled seroprevalence of CeD based on a positive anti-tissue transglutaminase antibody and/or anti-endomysial antibody was 4.8% (95% CI [2.8, 6.7%], I2 = 87.7%). The pooled biopsy-confirmed CeD prevalence was 1.5% (95% CI [1.0, 1.9%]; I2 = 59.8%) in these patients. Both seroprevalence (Odds ratio: 1.8; 95% CI [0.8, 4.0%]; I2 = 0%) and prevalence of biopsy-confirmed CeD (Odds ratio: 1.4; 95% CI [0.8, 2.4]; I2 = 0%) were not higher in patients with dyspepsia compared to controls. There was a moderate risk of selection bias and significant heterogeneity in the pooled results.

CONCLUSIONS

The pooled prevalence of CeD in patients with dyspepsia was 1.5% and it was not significantly higher than the general population. These results do not support screening of patients with dyspepsia for CeD.

Mean platelet volume can indicate dietary adherence and disease severity of celiac disease

Objective:

At present, there is no reliable indicator for dietary compliance and disease severity in patients with celiac disease (CD). The aim of this study is to evaluate mean platelet volume (MPV) level as a biomarker for detection of disease activation, dietary adherence, and assessment of disease severity.

Methods:

Eighty-one patients with CD and 50 healthy subjects were enrolled in this study. The diagnosis of CD was established by both positive antibodies against endomysium or gliadin and histopathological criteria (lymphocytic infiltration and total villous atrophy in duodenal biopsies).

Results:

MPV was observed to be significantly higher among CD patients when compared to healthy controls (8.14±0.26 fL vs. 7.82±0.29 fL and p=0.001). Overall dietary adherence rate was 72.8% (58/81 CD patients). After induction of a gluten-free diet, the MPV was significantly lower in the dietary adherent group than non-adherent patients (7.86±0.17 fL vs. 8.07±0.30 fL and p=0.001). The increase of MPV was correlated with Marsh classification (Marsh 3 active CD vs. Marsh 2 active CD vs. Marsh 1 active CD; 8.32±0.27 fL vs. 8.12±0.19 fL vs. 7.98±0.19 fL; p=0.004 and p=0.009).

Conclusion:

Based on these data, we believe that increased MPV can provide additional benefit to screening in patients with CD. It can indicate the activation of the disease and adherence to the diet.

Prevalence of celiac disease in patients with atypical presentations

BACKGROUND AND STUDY AIMS

Unawareness about atypical forms of celiac disease (CD) leads to the underdiagnoses of CD. This study has investigated the prevalence of CD in patients with atypical presentations, such as idiopathic low bone mineral density (ILBMD) and dyspepsia, in the Iranian population.

PATIENTS AND METHODS

Two separate groups of patients who have been diagnosed with dyspepsia and ILBMD (including either osteopenia or osteoporosis of unknown cause) were screened for CD during 2016-2019. Patients were serologically screened by means of IgA anti-tissue transglutaminase (IgA anti-tTG); in case of positive results, the patients underwent endoscopic intestinal biopsy to confirm the diagnosis of CD.

RESULTS

Of 200 patients with ILBMD, six (3%) had a positive result for IgA anti-tTG; in five cases (2.5%), duodenal histology confirmed the CD diagnosis. Of 290 patients with dyspepsia, 25 (8.6%) had a positive result for anti-tTG IgA; nine cases (3.7%) were histologically compatible with CD. No significant differences were found between the two groups of patients.

CONCLUSIONS

The prevalence of CD in patients with atypical presentations, such as ILBMD and dyspepsia, is consistent (pvalue = 0.788) and higher than that in the general population (p value = 0.001); therefore, screening program for CD in these patients is highly recommended.

Routine Multiple Duodenal Biopsy during Endoscopy of Dyspeptic Patients Seems Unnecessary for Screening of Celiac Disease

INTRODUCTION

Celiac disease (CD) is a chronic and common cause of dyspepsia with a rising prevalence worldwide. This study is aimed at investigating the prevalence of CD in dyspeptic patients based on serology and biopsy, determining the associated factors, and assessing the necessity of regular duodenal biopsies from normal mucosa in diagnosis of CD among dyspeptic patients.

METHODS

This cross-sectional study was performed on 530 adult dyspeptic patients who underwent gastroduodenoscopy in Imam Reza hospital, Mashhad, during 2016-2018. Demographic characteristics, clinical data, and laboratory analyses were extracted from hospital records. CD was diagnosed based on intestinal biopsy and serum antitissue transglutaminase (anti-TTG) levels. Mucosal lesions were classified according to the modified Marsh classification. Data were analyzed in SPSS with P < 0.05 being considered significant.

RESULTS

Overall, 163 males (30.8%) and 367 females (69.2%) with an average age of 46.38 ± 15.54 years were studied. High anti-TTG levels were seen in 36 (6.8%) patients, and duodenal pathologies were seen in 23 (4.5%) patients. Fifteen (2.8%) were diagnosed with CD based on both serology and biopsy. Bloating was the most common type of dyspepsia in CD patients (7, 46.7%), followed by epigastric pain (6, 40%), and postprandial fullness (2, 13.3%). Two CD patients (13.3%) reported a positive family history for CD. Logistic regression model showed that iron deficiency anemia (IDA), anti-TTG level, and Helicobacter pylori infection were predictors of histological changes of CD, whereas IDA was the only independent predictor of CD in dyspeptic patients (OR = 17.65, 95%CI = 1.53-202.52, and P = 0.021).

CONCLUSION

CD is prevalent in dyspeptic patients, but routine biopsy from normal-appearing duodenal mucosa is not recommended for all patients. Serological studies, complete history, and careful endoscopic evaluation may provide better cost-effective clinical solutions to improve the diagnostic yield of celiac disease in dyspeptic patients.

Endoscopic evaluation of celiac disease severity and its correlation with histopathological aspects of the duodenal mucosa

BACKGROUND AND STUDY AIMS

Celiac disease (CD) is a chronic systemic autoimmune disorder affecting genetically predisposed individuals, triggered and maintained by the ingestion of gluten. Triggered and maintained by the ingestion of gluten, celiac disease is a chronic systemic autoimmune disorder affecting genetically predisposed individuals. Persistent related inflammation of the duodenal mucosa causes atrophy architecture detectable on esophagogastroduodenoscopy (EGD) and histopathology. We investigated the association between endoscopic features and histopathological findings (Marsh) for duodenal mucosa in celiac disease patients and propose an endoscopic classification of severity.

PATIENTS AND METHODS

Between January 2000 and March 2010, an electronic database containing 34,540 EDGs of patients aged > 14 years was searched for cases of CD. Out of 109 cases, 85 met the inclusion criteria: conventional EGD combined with chromoendoscopy, zoom and biopsy. EGD types 0, I and II corresponds to Marsh grades 0, 1 and 2, respectively, while EGD type III corresponds to Marsh grade 3 and 4.

RESULTS

Five patients (5.8 %) were EGD I but not Marsh grade 1; 25 patients (29.4 %) were EGD II, 4 of whom (16 %) were classified as Marsh grade 2; and 55 patients (64.7 %) were EGD III, 51 (92.7 %) of whom were classified as Marsh grades 3 and 4. The Spearman correlation coefficient (r = 0.33) revealed a significant association between the methods (P = 0.002).

CONCLUSIONS

Changes in the duodenal mucosa detected on EGD were significantly and positively associated with histopathologic findings. The use of chromoendoscopy in addition to conventional EGD enhances changes in the duodenal mucosa and permits diagnosis of CD, even in routine examinations. The proposed endoscopic classification is practical and easily reproducible and provides valuable information regarding disease extension.

Evidence Against Routine Testing of Patients With Functional Gastrointestinal Disorders for Celiac Disease: A Population-based Study

BACKGROUND & AIMS

Celiac disease has been linked to irritable bowel syndrome (IBS)-like symptoms in outpatient clinics. Guidelines recommend that all patients with IBS-like symptoms undergo serologic testing for celiac disease, but there is controversy over whether celiac disease is more prevalent in populations with IBS-like symptoms. We aimed to determine whether positive results from serologic tests for celiac disease are associated with IBS and other functional gastrointestinal disorders (FGIDs) in a large U.S. white population.

METHODS

Validated, self-report bowel disease questionnaires (BDQs) were sent to randomly selected cohorts of Olmsted County, Minnesota residents. In separate protocols, serum samples were collected from more than 47,000 Olmsted County residents without a prior diagnosis of celiac disease; we performed serologic tests for celiac disease on stored serum samples from residents who completed the BDQ. Logistic regression was used to test for the association between serologic markers of celiac disease (positive vs negative) and individual FGIDs.

RESULTS

A total of 3202 subjects completed the BDQ and had serum available for testing. IBS was identified in 13.6% of these subjects (95% confidence interval [CI], 12.4%-14.8%), and any gastrointestinal symptom occurred in 55.2% (95% CI, 53.5%-56.9%). The prevalence of celiac disease on the basis of serologic markers was 1.0% (95% CI, 0.7%-1.4%). IBS was less prevalent in patients with celiac disease (3%) than patients without celiac disease (14%), although the difference was not statistically significant (odds ratio, 0.2; 95% CI, 0.03-1.5). Abdominal pain, constipation, weight loss, and dyspepsia were the most frequent symptom groups in subjects who were seropositive for celiac disease, but none of the gastrointestinal symptoms or disorders were significantly associated with celiac disease serology.

CONCLUSIONS

Symptoms indicative of FGIDs and seropositive celiac disease are relatively common in a U.S. white community. Testing for celiac disease in patients with IBS in the community may not have a significantly increased yield over population-based screening in the United States.

Dyspepsia and celiac disease: Prevalence, diagnostic tools and therapy

The prevalence of dyspepsia is up to 40% in population-based study. Functional dyspepsia is an exclusion diagnosis and it is classified as a chronic abdominal pain-related functional disorder, characterized by the presence of persistent or recurrent pain or discomfort centered in the upper abdomen, neither relief by defecation, nor association with the onset of a change in stool frequency or form. Celiac disease (CD) is a common autoimmune enteropathy, with a prevalence around 1% in the general population. Its diagnosis includes a serological screening and an upper gastrointestinal endoscopy with multiple biopsies. Gluten-free diet is the only effective treatment. CD diagnosis is often delayed in asymptomatic patients or in individuals with less clinical gastrointestinal symptoms. Several studies performed coeliac disease screening in patients with symptoms suggestive of dyspepsia, showing a biopsy-proved prevalence that ranged from 0.5% to 2%. The typical endoscopic markers of villous atrophy are not sufficiently sensitive, so some endoscopic techniques, such as “water immersion” and confocal endomicroscopy were proposed to improve the diagnostic sensitivity and target biopsies. A recent meta-analysis estimated that the prevalence of CD was higher in patients with dyspepsia, but not in a statistically significant way. However this assumption should be confirmed further larger studies.

Dyspepsia

PURPOSE OF REVIEW

A variety of organic diseases can cause dyspepsia, but most patients with epigastric pain have functional dyspepsia. As dyspepsia is common and usually has a benign cause, it is not possible to fully investigate everyone with epigastric pain. Current recommendations suggest that young patients without alarm symptoms can be treated empirically with Helicobacter pylori test and treat and proton pump inhibitor therapy can be offered to those who are negative or remain symptomatic despite treatment for their H. pylori. Patients who remain symptomatic with this strategy may be investigated with endoscopy, but most will have functional dyspepsia.

RECENT FINDINGS

There are a large number of trials for prokinetic therapy in functional dyspepsia, but treatment efficacy is uncertain, as there is evidence of publication bias. There are very limited data for the effectiveness of tricyclic antidepressants in functional dyspepsia. There has been recent interest in the observation that patients with functional dyspepsia have increased eosinophils in the duodenum and this may be accompanied by other subtle manifestations of upregulated mucosal immunity. It is possible that this is being driven by a dietary substance or by a change in the upper gut microbiome.

SUMMARY

The initial management of dyspepsia is well established, but how to manage those who do not respond is a challenge. Future studies evaluating diet and altering the gut microbiome may give clinicians more therapeutic options.

Spectrum of gluten-sensitive enteropathy in patients with dysmotility-like dyspepsia

BACKGROUND

Dysmotility-like dyspepsia symptoms are frequent in patients with gluten-sensitive enteropathy (GSE). Current data suggest that patients with mild enteropathy may be present with gluten-sensitive symptoms and complications.

AIM

To investigate the prevalence of GSE, including mild enteropathy, in patients with dysmotility-like dyspepsia symptoms.

METHODS

We retrospectively studied 142 patients who presented dysmotility-like dyspepsia symptoms and normal upper gastrointestinal endoscopy. Endoscopic duodenal biopsies were taken and processed using hematoxylin-eosin staining and CD3 immunophenotyping. In patients with enteropathy (number of intraepithelial lymphocytes greater than 25 per 100 enterocytes) we also performed coeliac serology (anti-tissue transglutaminase IgA) and HLA-DQ2/DQ8 genotyping. A gluten-free diet was offered if one of these markers was positive. The final GSE diagnosis was established based on clinical and histopathological response to the gluten-free diet after 18 months of follow-up.

RESULTS

Fifty-one patients (35.9%) had enteropathy; 4 (2.8%) Marsh type 3b, 24 (16.9%) Marsh type 3a, 3 (2.1%) Marsh type 2, and 20 (14.1%) Marsh type 1. A positive serology result was extremely low (6.7%) in mild enteropathy (Marsh type 1-3a) in contrast with Marsh type 3b patients (50%). Most patients with enteropathy had positive HLA DQ2 or -DQ8 genotyping (84.1%). Out of the 37 patients who started a gluten-free diet, 34 (91.9%) improved their symptoms, and 28 of 32 (87.5%) had a histopathological or serological response. A final GSE diagnosis was established in 28 of the 142 patients (19.7%).

CONCLUSION

Gluten-sensitive enteropathy can be a frequent and unsuspected cause of dysmotility-like dyspepsia.

[Gluten-sensitive enteropathy and functional dyspepsia]

Gluten-sensitive enteropathy (GSE) is increasingly diagnosed in adults. The symptoms of this disease can overlap with those of functional dyspepsia. The prevalence of GSE in dyspepsia has been reported to be 1.2-6.2% and could be higher if the entire spectrum of lesions related to gluten sensitivity, including lymphocytic enteropathy, is considered. Patients with dyspepsia secondary to GSE could be mistakenly diagnosed with functional dyspepsia unless upper gastrointestinal endoscopy is completed with duodenal biopsy and immunostaining for intraepithelial lymphocytes. A missed diagnosis could have major consequences in terms of morbidity and mortality and quality of life. Consequently, endoscopic study of patients with dyspepsia should be completed by duodenal biopsy when there are symptoms suggestive of GSE.

Mean platelet volume could be a promising biomarker to monitor dietary compliance in celiac disease

BACKGROUND

Celiac disease (CD) is an autoimmune disease that develops in patients with a genetic predisposition, incurring a susceptibility to gluten-containing foods such as barley, wheat, and rye. The elimination of gluten from the diet is the main therapeutic approach and usually leads to clinical and laboratory improvement. There are no ideal markers that objectively assess dietary compliance in CD patients.

MATERIALS AND METHODS

Sixty newly diagnosed CD patients (male/female: 43/17) and 40 healthy subjects (male/female: 23/17) were enrolled in this study. The diagnosis of CD was established by both histological findings of duodenum biopsy (total villous atrophy and lymphocytic infiltration) and positive antibodies against endomysium or gliadin.

RESULTS

A significantly higher mean platelet volume (MPV) was observed in the CD group compared with healthy subjects (8.45 ± 0.96 fL versus 7.93 ± 0.63 fL; p = 0.004). After introduction of a gluten-free diet, the MPV of CD patients in the dietary adherent group was significantly lower than that of the non-adherent group (8.09 ± 0.6 fL versus 8.9 ± 1.08 fL; p = 0.001). Overall dietary adherence rate was 71.6% (43/60 CD patients). In the dietary compliant group, initiation of gluten-free diet was associated with a significant decrease in MPV from base-line values (8.56 fL versus 8.25 fL; p = 0.008). In the non-adherent group, MPV on 3-month follow-up was higher than at base-line (8.05 fL versus 8.91 fL; p = 0.001).

CONCLUSION

MPV could be a promising and easily available biomarker for monitoring of dietary adherence in CD patients at a low cost in comparison with other modalities.

A Brazilian experience of the self transglutaminase-based test for celiac disease case finding and diet monitoring

AIM: To evaluate the effectiveness of a rapid and easy fingertip whole blood point-of-care test for celiac disease (CD) case finding and diet monitoring.

METHODS: Three hundred individuals, 206 females (68.7%) and 94 males (31.3%), were submitted to a rapid and easy immunoglobulin-A-class fingertip whole blood point-of-care test in the doctor’s office in order to make immediate clinical decisions: 13 healthy controls, 6 with CD suspicion, 46 treated celiacs, 84 relatives of the celiac patients, 69 patients with dyspepsia, 64 with irritable bowel syndrome (IBS), 8 with Crohn’s disease and 9 with other causes of diarrhea.

RESULTS: Upper gastrointestinal endoscopy with duodenal biopsies was performed in patients with CD suspicion and in individuals with positive test outcome: in 83.3% (5/6) of the patients with CD suspicion, in 100% of the patients that admitted gluten-free diet transgressions (6/6), in 3.8% of first-degree relatives (3/79) and in 2.9% of patients with dyspepsia (2/69). In all these individuals duodenal biopsies confirmed CD (Marsh’s histological classification). The studied test showed good correlation with serologic antibodies, endoscopic and histological findings.

CONCLUSION: The point-of-care test was as reliable as conventional serological tests in detecting CD cases and in CD diet monitoring.

Meta-analysis: yield of diagnostic tests for coeliac disease in dyspepsia

BACKGROUND

The prevalence of coeliac disease (CD) may be increased in individuals with dyspepsia, but evidence is conflicting.

AIMS

To conduct a systematic review and meta-analysis of studies reporting prevalence of CD in dyspepsia.

METHODS

MEDLINE, EMBASE, and CINAHL were searched up to February 2009. Case series and case-control studies applying serological tests and/or distal duodenal biopsy for CD to unselected adults with dyspepsia were eligible. Prevalence of positive coeliac serology and biopsy-proven CD were pooled for all studies and compared between cases and controls using an odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Fifteen studies were identified. Prevalence of positive coeliac serology was higher in cases with dyspepsia (7.9%) compared with controls (3.9%), but not significantly so (OR for positive endomysial antibodies or tissue transglutaminase 1.89; 95% CI 0.90-3.99). Prevalence of biopsy-proven CD following positive serology was also higher (3.2% in cases vs. 1.3% in controls), but again this was not statistically significant (OR 2.85; 95% CI 0.60-13.38). Prevalence of biopsy-proven CD was 1% in ten studies performing duodenal biopsy first-line.

CONCLUSION

Prevalence of biopsy-proven CD in subjects with dyspepsia was 1% and was higher than in controls, although this difference was not statistically significant.